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Background and Purpose— The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion. Methods— Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0–2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy. Results— We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age P Conclusions— Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02419794.

Acute basilar artery occlusion (BAO) is associated with major morbidities and a high mortality rate. The prevalence of acute BAO is 10.4% among patients treated with thrombectomy for acute large vessel occlusion. Vertebral artery stump syndrome (VASS) reportedly causes ischemic stroke with tandem occlusions as vertebral artery (VA) origin occlusion and BAO. The pathogenesis of ischemic stroke due to VASS can be attributed to thrombi or emboli. Acute embolic BAO due to VASS accounted for 2 of 25 cases (8.0%) of BAO treated using thrombectomy between April 2014 and May 2019 in our registry. VASS must be considered as one cause of BAO. With the initial Magnetic resonance angiography on arrival, it is difficult to distinguish between BAO due to simple cardiogenic embolus and due to embolus caused by VASS rapidly. In patients suffering from acute embolic BAO due to VASS, the presence of VA origin occlusion makes endovascular therapy (EVT) difficult to perform. Here, we report consecutive cases of thrombectomy for acute embolic BAO due to VASS, showing markedly different outcomes. VA origin occlusion severely limits the technical options for EVT. Visualization or conjecture of the origin of both or dominant VAs conceivably offers the possibility of successful EVT and may allow good outcomes.

The purpose of this study was to investigate the in-hospital acute ischemic stroke due to large vessel occlusion (LVO) that developed in another thrombectomy-incapable hospital, treated by mechanical thrombectomy after inter-hospital transfer. In eight other hospital-onset LVO patients, clinical characteristics, treatment results, and the timeline of thrombectomy were retrospectively investigated and compared to the results of 17 patients developed LVO at our own hospital and 18 developed in the community. In the analysis of timeline, the mean recognition-to-arrival time in other hospital-onset patients was 169 ± 78 min, significantly longer than for the community-onset patients (79 ± 78 min). Arrival-to-puncture time was 42 ± 19 min, significantly shorter than for the own hospital-onset patients (166 ± 80 min) and the community-onset patients (155 ± 76 min). Recognition-to-puncture times for the other hospital-onset patients, the own hospital-onset patients, and the community-onset patients were 212 ± 74, 166 ± 80, and 216 ± 83 min, respectively, and recognition-to-recanalization times were 285 ± 73, 200 ± 81, and 275 ± 125 min. Both these times were shorter for the own hospital-onset patients. The rates of modified Rankin Scale (mRS) of 0-2 in the three groups were 12%, 30%, and 23%, respectively. The rate of mRS 0-2 was lowest in the other hospital-onset patients. In conclusion, the other hospital-onset patients required additional time for their initial management and inter-hospital transfer although arrival-to-puncture time was shorter. Favorable outcomes were observed less frequently in them. Improving inter-hospital cooperation systems and to educate the medical staff in a thrombectomy-incapable hospital concerning stroke management is important measures for other hospital-onset stroke with LVO.

In this paper, we propose a fine-grained packet identification and control technique using a combination of commercial routers and programmable switches in existing IP networks. This technique enhances the control of existing users' communication in large-scale networks such as carrier networks, by utilizing the large amount of user-premises equipment and terminals already installed without modifying as much as possible. The packet identification in commercial routers involves not only identifying the destination address by the routing table but also filtering the arriving packets for access control. However, in large networks, the number of entries in the router can easily exceed the upper limit of the specification due to the bloated number of entries. The purpose of our proposal is to introduce programmable switches to apply fine-grained entries to specific packets roughly identified by commercial routers, thereby distributing the entries and achieving fine-grained packet identification even in large-scale networks. In our demonstration, we will target an MPLS VPN network and demonstrate how to forward packets of only specific users to P4 switches and how to flow only specific applications to high priority paths.

Introduction An enlarged scrotum due to scrotal elephantiasis results in a poor quality of life. This condition is uncommon and challenging to manage for most urologists. We report a case of scrotal elephantiasis treated with resection and scrotal reconstruction. Case presentation A 57-year-old man was referred to our hospital with a 6-year history of scrotal swelling. The scrotum was 20 cm in diameter, stiff, and thick. He was diagnosed with chronic scrotal lymphedema and underwent scrotal resection. The skin and subcutaneous tissues of the scrotum were excised, and the suprapubic skin, which was stretched by the enlarged scrotum, was used for the scrotal reconstruction. The penis was pulled out from this hole in the skin. Conclusion Utilizing suprapubic skin flap for scrotal reconstruction is an effective treatment for scrotal elephantiasis that can result in functionally and cosmetically successful outcomes.

Ruptured blood-blister aneurysms (RBBAs) of the intracranial internal carotid artery (ICA) are associated with high morbidity and mortality. RBBA has been treated with trapping with high-flow bypass avoiding manipulation of RBBA. In case of the presence of persistent primitive trigeminal artery (PPTA), it is necessary to preserve the antegrade blood flow of PPTA because avoiding ischemic complications. Here, we present a case of RBBA concomitant with ipsilateral PPTA successfully treated with multistaged overlapping braided stents maintaining PPTA flow. A 30-year-old woman suffered from headache and was diagnosed RBBA of the intracranial ICA concomitant with ipsilateral PPTA. A reconstructive endovascular treatment using low-profile visualized intraluminal support (LVIS) stent was performed. However, it has recurred, and RBBA has finally been occluded after overlapping LVIS stents with coil sandwich that is not yet reported in the literature. We report the first case of overlapping LVIS stents with coil sandwich for RBBA.

Background and Purpose: We determined to identify patients with unknown onset stroke who could have favorable 90-day outcomes after low-dose thrombolysis from the THAWS (Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes With Alteplase at 0.6 mg/kg) database. Methods: This was a subanalysis of an investigator-initiated, multicenter, randomized, open-label, blinded–end point trial. Patients with stroke with a time last-known-well >4.5 hours who showed a mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg intravenously or standard medical treatment. The patients were dichotomized by ischemic core size or National Institutes of Health Stroke Scale score, and the effects of assigned treatments were compared in each group. The efficacy outcome was favorable outcome at 90 days, defined as a modified Rankin Scale score of 0 to 1. Results: The median DWI-Alberta Stroke Program Early CT Score (ASPECTS) was 9, and the median ischemic core volume was 2.5 mL. Both favorable outcome (47.1% versus 48.3%) and any intracranial hemorrhage (26% versus 14%) at 22 to 36 hours were comparable between the 68 thrombolyzed patients and the 58 control patients. There was a significant treatment-by-cohort interaction for favorable outcome between dichotomized patients by ASPECTS on DWI ( P =0.026) and core volume ( P =0.035). Favorable outcome was more common in the alteplase group than in the control group in patients with DWI-ASPECTS 5 to 8 (RR, 4.75 [95% CI, 1.33–30.2]), although not in patients with DWI-ASPECTS 9 to 10. Favorable outcome tended to be more common in the alteplase group than in the control group in patients with core volume >6.4 mL (RR, 6.15 [95% CI, 0.87–43.64]), although not in patients with volume ≤6.4 mL. The frequency of any intracranial hemorrhage did not differ significantly between the 2 treatment groups in any dichotomized patients. Conclusions: Patients developing unknown onset stroke with DWI-ASPECTS 5 to 8 showed favorable outcomes more commonly after low-dose thrombolysis than after standard treatment. Registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT02002325. URL: https://www.umin.ac.jp/ctr ; Unique Identifier: UMIN000011630.

Background Statins have been associated with reduced recurrence and better functional outcomes in patients with acute ischemic stroke. However, the effect of statins in patients with acute large vessel occlusion (LVO) is not well scrutinized. Methods and Results RESCUE (Recovery by Endovascular Salvage for Cerebral Ultra‐Acute Embolism)‐Japan Registry 2, a physician‐initiated registry, enrolled 2420 consecutive patients with acute LVO who were admitted to 46 centers across Japan within 24 hours of onset. We compared patients with and without statin use after acute LVO onset (statin group and nonstatin group, respectively) in terms of the modified Rankin scale at 90 days. We estimated that the odds ratios for the primary outcome was modified Rankin scale and we estimated the odds ratios for a 1‐scale lower modified Rankin scale adjusting for confounders. After excluding 12 patients without LVO and 9 patients without follow‐up, the mean age of 2399 patients was 75.9 years; men accounted for 55% of patients. Statins were administered to 447 (19%) patients after acute LVO onset. Patients in the statin group had more atherothrombotic cerebral infarctions (34.2% versus 12.1%, P P P P =0.02). The mortality at 90 days was lower in the statin group (4.7%) than the nonstatin group (12.5%; P P =0.02). Conclusions Statin administration after acute LVO onset is significantly associated with better functional outcome and mortality at 90 days.

Crush syndrome (CS) is caused by severe and extensive muscular skeletal damages, and acute kidney injury (AKI) with hyperkalemia is one of the most lethal factors of this syndrome. Especially under natural disasters of earthquake, many persons die due to AKI and hyperkalemia-induced cardiac arrest, but there has been no pathogenesis-based drugs for preventing CS-induced AKI. Pro-inflammatory cytokines, such as TNF-α and IL-6, play a critical role for induction of AKI during CS development. Glycerol-injected mice are used as an experimental tool for reflecting pathological events of human CS. Using this popular model, we provide evidence to show that TNF type-I receptor (TNFR1) inhibitor, R-7050 significantly attenuates the onset of AKI after the muscular destruction. In this process, R-7050 treatment suppressed the NF-κB activation in the affected kidney, and this was associated with a decrease in blood IL-6, a downstream target of NF-κB. As a result, renal tubular apoptosis became milder in the R-7050-treated CS mice. These findings suggest that induction of IL-6 via sequential events of TNF-α a TNFR1 a NF-κB is contributable for renal tubular apoptosis, a histological hallmark of AKI. Thus, TNFR1-selective inhibition can be a pharmacological strategy to attenuate the onset of AKI immediately after the clinical manifestation of rhabdomyolysis.

A 48-year-old female with a symptomatic giant carotid cavernous aneurysm underwent endovascular treatment with multiple Pipeline Flex embolic devices (PED). The delivery catheter had to take a complicated course of multiple turns to cross the aneurysm, and its loop was tied in the aneurysm. When the catheter was to be withdrawn, it was apparent that the tied catheter had made a tight knot that bound the tail of the previous PED together. We successfully retrieved all of the system including the tied PED, and we used telescoping stents with five PEDs in the next operation. Although this is a rare complication, it is worth noting and checking to make sure that there is no knot before deploying the stent.

Ischemic stroke is one of the most common complications of infective endocarditis (IE). IE must be considered as one of the causes of acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO), but early diagnosis of IE is difficult. AIS with ELVO must be treated using endovascular thrombectomy (EVT), with or without intravenous thrombolysis (IVT). IVT for AIS due to IE is not well established and remains controversial because of the risk of intracranial hemorrhage. A 42-year-old man suffered from right hemiparesis and disorientation, and AIS with ELVO was diagnosed. EVT with IVT was successfully performed and recanalization was achieved, but catastrophic multiple cerebral microbleeds appeared after treatment. EVT without IVT could be chosen for AIS caused by IE to avoid hemorrhagic complications. Hypointense signal spots on T2*-weighted magnetic resonance imaging (MRI) and susceptibility-weighted MRI could facilitate early diagnosis of IE.

Background: Endovascular treatment for acute tandem occlusion (ATO) of the combination of an ipsilateral extracranial internal carotid artery (ICA) steno-occlusive lesion with concurrent intracranial artery occlusion is challenging. Whether extracranial lesions, especially in cases of the left common carotid artery (LCCA) origin steno-occlusive lesions, should be treated after recanalization of an occluded intracranial artery by mechanical thrombectomy simultaneously in the same session has not been established. We report two cases of successful ATO with LCCA origin steno-occlusive lesions treated by staged retrograde transcarotid LCCA stenting followed emergent mechanical thrombectomy in two sessions because of the tortuous aortic arch. Case Description: A 61-year-old man with left ICA occlusion and an 82-year-old woman with left middle cerebral artery occlusion underwent emergent mechanical thrombectomy for ATO with LCCA origin stenoocclusive lesions. We achieved recanalization of large vessels, but severe stenosis of LCCAs remained. Because of the tortuous aortic arch, we decided to treat LCCA origin steno-occlusive lesions with staged stenting in the other session followed emergent mechanical thrombectomy. Postoperative courses were uneventful, and their symptoms improved. We performed stenting using a transcarotid approach through CCA cut down for LCCA steno-occlusive lesions without any complications. Conclusion: The staged strategy leaving LCCA origin stenosis seems to offer a better strategy than the simultaneous strategy for ATO with LCCA origin steno-occlusive lesions. A retrograde transcarotid approach through CCA cut down is recommended for LCCA stenting.

Purpose Conventional coil embolization for large carotid cavernous aneurysms (CCAs) has limited utility due to its inability to prevent recurrences and reduce mass effect. Trapping of the parent artery may have a risk of ischemic complications due to intracranial perfusion disorders. We successfully treated 24 patients with large CCAs using a flow diverter (Pipeline™ embolic device: PED), and this report discusses the safety and efficacy of this method. Materials and methods Twenty four patients (23 females, mean age 71.5 years old) with large CCAs, including 6 giant CCAs, were treated with a PED over three years. Under sufficient dual anti-platelet management, the PED was deployed over the orifice of the aneurysm. Two patients required multiple telescoping stents. Clinical and radiological states were checked with MRI at 1, 3 and 6 months post-surgically. Angiographic follow-up was performed at 6 months. Results In all patients, PED was appropriately deployed. Stagnation of contrast with eclipse signs was observed post-angiogram in 21 cases. One patient requiring 5 telescoping stents experienced temporary ischemic symptoms. Fourteen patients experienced improvement of ocular motor impairment deficiency, including 6 patients who recovered. Angiograms at 6 months follow-up showed complete occlusion in 63% (12/19) of patients, and MRI showed reduction of aneurysm volume in 89% (17/19) of patients. Conclusion Flow diverters for large CCAs showed promising clinical and radiological efficacy. They can shrink the aneurysm and improve symptoms without sacrificing the parent artery. It will be necessary to summarize the cases and to verify the long-term results.

The relationship between stroke etiology and clot pathology remains controversial.We performed histological analysis of clots retrieved from 52 acute ischemic stroke patients using hematoxylin and eosin staining and immunohistochemistry (CD42b and oxidative/hypoxic stress markers). The correlations between clot composition and the stroke etiological group (i.e., cardioembolic, cryptogenic, or large artery atherosclerosis) were assessed.Of the 52 clots analyzed, there were no significant differences in histopathologic composition (e.g., white blood cells, red blood cells, fibrin, and platelets) between the 3 etiological groups (P = .92). By contrast, all large artery atherosclerosis clots showed a localized pattern with the oxidative stress marker 4-hydroxyl-2-nonenal (P.01). From all 52 clots, 4-hydroxyl-2-nonenal expression patterns were localized in 28.8% of clots, diffuse in 57.7% of clots, and no signal in 13.5% of clots.A localized pattern of 4-hydroxyl-2-nonenal staining may be a novel and effective marker for large artery atherosclerosis (sensitivity 100%, specificity 82%).

Background Endovascular therapy has been shown to be effective in patients with acute cerebral large‐vessel occlusion, but real‐world efficacies are unknown. Methods and Results We conducted a prospective registry at 46 centers between October 2014 and January 2017. Eligible patients were those who were aged 20 years or older, with acute cerebral large‐vessel occlusion, and who were hospitalized within 24 hours of the onset. We enrolled both consecutive patients who were treated with or without endovascular therapy. Endovascular therapy included thrombectomy, balloon angioplasty, stenting, local fibrinolysis, and piercing. The primary outcome was a favorable outcome as defined by a modified Rankin Scale of 0 to 2 at 90 days after onset. Secondary outcomes were modified Rankin Scale of 0 to 1 and mortality. Safety outcomes were intracerebral hemorrhage or a recurrence of ischemic stroke. We constructed the 2242 (1121 each) propensity score–matched patients cohort based on a propensity score for endovascular therapy and estimated the adjusted odds ratio, followed by sensitivity analyses on original 2399 (1278 in endovascular therapy versus 1121 in no endovascular therapy) patients. In the propensity score–matched cohort, favorable outcomes were observed in 35.3% and 30.7% of patients in the endovascular therapy and no endovascular therapy groups, respectively ( P= 0.02). The adjusted odds ratio for the favorable outcome was 1.44 (95% confidence interval, 1.10–1.86, P =0.007). The efficacy of endovascular therapy in achieving favorable outcomes did not differ between our subgroups and in the sensitivity analyses. Conclusions Endovascular therapy decreased disabilities at 90 days in real‐world patients with acute cerebral large‐vessel occlusion. Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT02419794.

For many years, the pathophysiology of idiopathic intracranial hypertension (IIH) was interpreted as “secondary intracranial hypertension,” and IIH was considered to be caused by brain edema due to obstructive sleep apnea. Another theory proposed cerebrospinal fluid (CSF) absorption impairment due to excessive medication with vitamin A derivatives. Other reports pointed out the importance of obesity, which may cause an impairment of intracranial venous drainage due to elevated right atrial pressure. Patients with medically refractory IIH have traditionally undergone a CSF diversion. Venous outlet impairment on IIH has recently been reported as a causative or contributory cause, and thus focused venoplasty of the stenotic sinus with a stent has emerged as a new treatment strategy. We report the cases of two patients who presented with headache and papilledema with IIH. They successfully underwent stent placement at the stenosis of the transverse sinus and experienced complete resolution of symptoms.

Endovascular thrombectomy is recommended for a persistent ischemic penumbra if recanalization cannot be achieved by the intravenous (IV) administration of recombinant tissue-plasminogen activator (rt-PA) alone. Although endovascular thrombectomy is a powerful treatment for major cerebral artery occlusion, the monitoring of recanalization and reperfusion during acute ischemic stroke presents a therapeutic challenge, and a previous study reported the usefulness of near-infrared spectroscopy (NIRS) for intraoperative monitoring during emergency endovascular thrombectomy for acute large ischemic stroke. Here we present our experience with a relevant case series. We applied NIRS monitoring during endovascular thrombectomy in two patients with large ischemic stroke following carotid artery occlusion and one patient with a non-large ischemic stroke caused by a distal middle cerebral artery (MCA) occlusion. In the patients with large ischemic stroke, complete recanalization of the internal carotid artery was achieved, and NIRS revealed a very good regional oxygen saturation (rSO2) response. By contrast, in the patient with non-large ischemic stroke, the rSO2 did not change, despite complete recanalization of the distal MCA. Our findings suggest the limited usefulness of intraoperative NIRS monitoring during emergency endovascular thrombectomy for non-large acute ischemic stroke caused by a distal MCA occlusion. However, intraoperative NIRS monitoring could be used practically to detect recanalization of the major artery during thrombectomy and early IV rt-PA administration in cases involving major artery occlusion.

Background The frequency of the occurrence of adverse events associated with carotid artery stenting (CAS) is usually low, but serious adverse events such as cerebral hyperperfusion syndrome (CHS) may occur. Real-time monitoring is ideal for the early detection of adverse events during the surgical procedure. This study aimed to evaluate continuous blood glucose (BG) monitoring for the detection of adverse events during CAS. Methods Forty patients undergoing scheduled CAS were prospectively enrolled. An artificial pancreas was used for continuous BG monitoring (once per minute), using venous blood extracted at a rate of 2 mL/hr during CAS. The primary endpoint was a correlation between BG change and adverse events. Results CAS was discontinued in 1 patient, and BG was not measured in 5 patients (12.5%) because of the inability to extract blood. Among 34 evaluable patients, no patient developed CHS, but 3 patients (9%) experienced carotid occlusion intolerance. During CAS, BG was significantly higher in patients with carotid occlusion intolerance (median: 5 mg/dL) than in patients without carotid occlusion intolerance (median: 0 mg/dL) (P = 0.0221). A cutoff BG value ≥4 mg/dL during CAS showed 50% sensitivity and 100% specificity for the detection of carotid occlusion intolerance. There was no significant correlation between BG change and other adverse events. Conclusions BG elevation may help detect carotid occlusion intolerance although it is still unknown whether BG monitoring can detect CHS. Further studies should validate that a cutoff BG elevation value of ≥4 mg/dL during CAS indicates carotid occlusion intolerance.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare central nervous system inflammatory disease characterized by the punctate gadolinium enhancement peppering the pons and the cerebellar peduncles as neuroimaging. We report the case of a 66-year-old woman who presented with CLIPPERS associated with swelling in the brainstem. She was hospitalized because of gait ataxia and consciousness disturbance. MRI of the brain showed FLAIR hyperintense lesions in the pons, cerebellar peduncles, cerebellum and the subcortical white matter lesion in the right occipital lobe with significant swelling in the brainstem. Diffusion-weighted MRI did not show an abnormal signal, indicating vasogenic edema. Post-contrast T1-weighted MRI showed enhanced area in the right occipital lobe and panctate gadolinium enhancement peppering brainstem. Treatment with steroids led to rapid improvement. However, she showed exacerbation of clinical and radiological findings during the tapering schedule of steroid. The biopsy from the occipital lobe revealed intense perivascular and parenchymal lymphocytic infiltrates composed of primarily T cells, B cells and macrophages. The patient was diagnosed with CLIPPERS, and treatment with increased dose of corticosteroid induced a clinical improvement. Previous reports well described a characteristic MRI finding of punctate enhancement peppering the pons. In addition, the pons and cerebellar peduncles swelling can occur in this disorder.

Vasospasm (VS) and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) are thought to greatly affect prognosis. Haptoglobin (Hp) is a hemoglobin-binding protein expressed by a genetic polymorphism (1-1, 2-1, and 2-2). Our objects were to investigate whether the Hp phenotype could predict the incidence of cerebral infarction, favorable outcome, clinical deterioration by DCI, and angiographical VS after aneurysmal SAH. Ninety-five consecutive patients who underwent clipping or coil embolization were studied. Favorable functional outcome was defined as a modified Rankin Scale score of 0-2 at 3 months. Angiographical VS was diagnosed based on cerebral angiography findings performed between days 7 and 10 after SAH. The Hp 2-2 group had a significantly greater risk of angiographical VS than that of Hp 2-1 and 1-1 groups combined on univariate (odds ratio [OR]: 3.60, confidence interval [CI]: 1.49-8.67, P = .003) and multivariate logistic regression analyses after being adjusted for age, sex, Fisher groups, and other risk factors (OR: 3.75, CI: 1.54-9.16, P = .004). The Hp 2-2 group also showed the tendency of a greater risk of clinical deterioration by DCI with marginal significance on univariate and age- and sex-adjusted analyses (univariate OR: 2.46, CI: .90-6.74, P = .080; age- and sex-adjusted OR: 2.46, CI: .89-6.82, P = .080) but not after being adjusted for other multiple risk factors. The Hp 2-2 group was not associated with the favorable 3-month outcome and cerebral infarction (univariate: P = .867, P = .209; multivariate: P = .905, P = .292). The Hp phenotype seems to be associated with a higher rate of angiographical VS and clinical deterioration by DCI but does not affect the incidence of cerebral infarction and favorable outcome.

The authors report a case of concurrent moyamoya disease and glycogen storage disease Type 1a that was successfully managed with bypass surgery. This 7-year-old Japanese girl, diagnosed with glycogen storage disease Type 1a at the age of 2 years, presented with repeated transient ischemic attacks. Cerebral angiography revealed severe stenosis at the terminal portions of the bilateral internal carotid arteries, with typical moyamoya vessels. The patient underwent superficial temporal artery–middle cerebral artery anastomosis and encephalomyosynangiosis bilaterally, in 2 staged procedures at an interval of 4 months. Despite perioperative administration of glucose, hypoglycemia and metabolic acidosis occurred after both surgeries. The symptoms were milder after the second surgery, in which an increased dose of glucose was used. The patient tolerated the perioperative conditions well under intensified medical treatment, and no further ischemic symptoms occurred.

Using the reduction gears with inclined planetary gear and arc tooth bevel gear, the vibrational accelerations in vertical direction of this system, with and without the backlash, are measured by changing the load torque and the input shaft speed. And, the materials of cylindrical pin attaching part of fixed and output gears are changed to alloy tool steel and cast iron, and the vibrational accelerations of this system are measured, and the results are discussed. The results are as follows : In the vibration characteristics of this system, meshing frequency component is main, and the natural frequencies caused by the torsional vibration of gears and the vibration of casing supporting the input shaft, are appeared. The vibrational acceleration of the system without the backlash is slightly lower than that with the backlash. Meshing frequency component has remarkably appeared in the vibrational acceleration, when the material in the cylindrical pin attaching part was changed from alloy tool steel to cast iron. However, in this system, the effect of the high damping capacity of gray cast iron has not appeared.

With the spread of broadband and wireless Internet access, there is a growing need for a nomadic network environment that enables the use of network services anywhere, via various access media. In a nomadic network environment, however, the connectivity is decreased because users move among different access networks, and the bandwidth is narrow and fluctuating, especially for radio propagation in wireless networks. To solve these problems, we propose a multilink system with three key functions: IPinIP tunneling, dynamic distribution of packets, and reordering of distributed packets. In particular, our distribution function includes a novel algorithm based on available bandwidth estimation. A prototype of our system was evaluated through experiments using real wireless environments and its efficiency is discussed.

Background Electron-beam tomography (EBT) may provide useful information about characterization and morphology of atherosclerotic plaque of coronary arteries. Materials and methods Twenty-six subjects (20 male, 6 female) with suspected coronary heart disease had two routine (r) and one enhanced (e) EBT scans to detect non-calcified plaque (NCP) in the coronary arterial lumen, and were compared with conventional coronary angiograms (CAG) and intravascular ultrasound (IVUS). Results Three had the sites, which did not have high CT values suggesting calcification in rEBT, nor which was not enhanced by contrast material in eEBT. One had the site with positive CT values that were supposed to be the proliferation intima or organized thrombus and at the corresponding site mixed plaque was observed in the IVUS image. The other two had the site with negative CT values that were supposed to be fat tissue with significant stenosis in CAG. We also made the cross-sectional images of the vessel and the morphology of the NCP, which projected into the lumen, could be evaluated. Conclusions We could detect the NCP, differentiate fat tissue from soft tissue and evaluate the morphology of the plaque in EBT.

We propose a method for estimating the locations of the causes of failure or deterioration in quality in the service function chains (SFCs) of datacenter networks by using tests packets. Our method is especially effective in service-quality deterioration where no alarms are notified from physical and virtual components. This method models SFC configurations by creating a correlation ID, which identifies a correlation between physical network elements and virtualized elements of the SFC components to enable us to find the components common to all SFCs that are either in failure or deteriorating. We consider such common components as locations where service problems can occur in SFCs. As a result of applying this method to SFCs in datacenter networks, it drastically reduced the number of candidate causes and computation time.

Carcinogenic responses in the prostate to 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) were compared among seven rat strains (F344, ACI, Spontaneously Hypertensive Rat (SHR), Sprague-Dawley (SD), Wistar, Lewis and Brown Norway (BN)). Ten-week-old animals of each strain were given PhIP at 400 ppm in the diet for 20 weeks then maintained until week 54. The final survival rates were 92, 92, 83, 75, 67, 42 and 42%, respectively, and the SHR strain showed the highest sensitivity with regard to development of prostatic intraepithelial neoplasias (PINs) in the ventral prostate. With regard to the induction of adenocarcinomas of the ventral prostate, the ACI strain was most sensitive, whereas Lewis and F344 rats were relatively resistant. No adenocarcinomas were found in the dorsolateral or anterior prostate or seminal vesicles in any of the strains. The levels of serum testosterone and estrogen, PhIP-DNA adducts and cell kinetics did not correlate with the development of ventral prostatic lesions and thus other factors are presumably responsible for the variations in susceptibility. The present data indicate that ACI and SHR rats are appropriate strains for experimental investigation of PhIP-induced prostate carcinogenesis.

Mobile IP has gained attention as a technology that can provide mobility to universal users independently of the access network. The introduction of Mobile IP in mobile core networks is currently under investigation. This paper discusses route optimization methods when Mobile IP technology is applied to mobile core networks. More specifically, it discusses means of resolving the “Triangle Routing” problem, which occurs when communications from a correspondent node to a mobile node must be routed through a Home Agent (HA). This paper first describes the conventional route optimization method being investigated by the Internet Engineering Task Force (IETF) and indicates problems with that method. It then proposes a new Mobile IP Border Gateway (MBG) method for solving the problems of the conventional method. The MBG method enables packets that arrive from another network to be directly received at the mobile node by having a Border Gateway router maintain Binding Information consisting of the care-of address and home address that were originally being maintained by the Home Agent for the communicating node. This paper also shows that introducing the MBG method enables the mean route length within the network to be shortened and the traffic volume routed through the Home Agent to be reduced. Finally, it shows methods of reducing the burden of registering Binding Information at the Mobile IP Border Gateway and indicates the applicability of the MBG method to large-scale mobile communications networks. © 2002 Wiley Periodicals, Inc. Electron Comm Jpn Pt 1, 86(2): 31–41, 2003; Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/ecja.1151

90歳以上の超高齢者腹部大動脈瘤手術の報告例は希である. われわれは92歳女性および91歳男性の腹部大動脈瘤手術を経験した. 前者は切迫破裂にて緊急手術, 後者は待期手術であった. 後者は術前には山登りをするほどの活動性にもかかわらず, 術後はまったく無気力で, 退院後も活動性は回復しなかった. 逆に, 前者は術前の活動性はさほど良好ではなく, 緊急症例であったにもかかわらず, 術後の活動性は良好であった. 術前の予想と逆の術後経過をたどった2症例の経験を通じて, われわれは超高齢者の術前予測の困難さと適応決定の難しさを痛感した. 超高齢者における予備能の低下は, 術前の活動性の高さや一般的なリスク評価とは必ずしも一致せず, 現段階においては個々の症例に対し柔軟性をもって対応すべきである.

Digital video compression schemes have been evaluated to determine which is the most suitable for storaging and transmitting broadcasting contents. Various types of digital compression devices have been proposed and developed for the transmitting and storaging video images, and some of these are now being applied to broadcasting applications. We investigated the application of digital video-compression techniques to digital-broadcasting contribution, distribution, and transmission, and conducted a subjective evaluation of cascaded combinations for broadcasting systems. On the basis of this work, we have developed a system for assessing the quality of compressed digital pictures, in which picture degradation is calculated in realtime and takes account of human visual perception. In this system, noise sensitivities considered in spatiotemporal frequencies in relation to picture brightness. This approach improves the accuracy of picture quality assessment for many types of degradations in comparison with the conventional picture quality scale method.

We herein report a case with an aneurysm of the right sinus of Valsalva, which developed 14 years after an aortic valve replacement (AVR) for aortic regurgitation caused by Takayasu arteritis. The aortic wall around the right coronary artery ostium showed calcification, as a result, the modified Bentall procedure and coronary artery bypass to the right coronary artery were successfully performed. A pathological study of the resected aortic sinus wall showed a disruption of the elastic fibers in the media, granuloma formation, and a marked proliferation of the collagen fibers in the adventitia, and these findings were compatible with Takayasu arteritis. The development of an aneurysm of the sinus of Valsalva late after AVR indicates the necessity of a close and lifelong follow-up for patients with Takayasu arteritis, especially focusing on the aortic root morphology.

Angiogenesis is an important event for organ development and regeneration via supply of nutrition and oxygen. Appropriate cellular responses, such as endothelial cell (EC) growth, are involved in the angiogenic actions, especially under hypoxic conditions. Hepatocyte growth factor (HGF) is now an organotrophic factor that is essential for organ development and tissue regeneration. In addition, HGF is the most potent angiogenic growth factor in culture of ECs, with mitogenic, and morphogenic functions via activation of c-Met/HGF-receptor. In hypoxic diseases, such as coronary arterial disease (CAD), up-regulation of HGF production is transient, followed by the HGF-deficient conditions, along with the lowered angiogenesis and enhanced hypoxia. Enhancement of angiogenesis by exogenous HGF leads to the improvement in heart dysfunction. Such angio-therapeutic effects of HGF are also seen in various hypoxic diseases, such as skin ulcer and lung emphysema. In tumor tissues, angiogenesis is required for cancer growth and metastasis. Indeed, an HGF-antagonist, NK4, potently inhibits tumor angiogenesis and metastasis in mouse models of malignant tumors. These provide a rationale why HGF is useful for the improvement in CAD and other ischemic diseases and NK4 for the suppression of tumor malignancy. Importantly, appropriate HGF-c-Met signal is required for sustaining homeostasis in normal tissue. Herein, we provide a concept that amount of HGF may determine the predisposition to ischemic disease, healthy conditions, or neoplastic disease, all of which depend on the degree of c-Met activation, and in part, concomitant angiogenic activity.

An experimental study was conducted on the behavior of the fuel spray and the nozzle needle in a multihole valve cut orifice (VCO) nozzle for diesel engines. The measurements of time lag for fuel discharge among individual holes and the photographic observation of fuel sprays at an arbitrary instant after the start of fuel discharge were carried out using a video camera and a microflash. The magnified image of the top portion of the nozzle needle illuminated by an argon laser and two He-Ne lasers was observed using a high-speed video camera through a window of diameter 0. 6 mm installed at the nozzle tip. The results showed that the fuel spray was classified into solid cone, hollow cone and mixed types, and that the radial displacement of the nozzle needle was straight and toward the opposite side of the hole from which the earliest fuel spray appeared among the five holes.

An experimental study was performed on the structure of a diesel spray at the initial stage of fuel injection. The nozzle tested was multi-hole valve cut orifice (VCO) nozzle. The experimental procedure consisted of illuminaiting the fuel spray by a stroboscope at an arbitrary instant and observing the image of the various sections of the fuel spray by a VTR set. Spray tip penetration and spray angle were measured under various back pressures ranging from 0.1 Mpa to 3 Mpa. The results showed that the fuel sprays were classified into solid cone, hollow and mixed type. The structures of each type of fuel sprays were clarified. The spray tip penetration of the solid cone spray and the solid cone portion in the mixed type sprays increased with time in the same way and that of the hollow cone spray showed a maximum at 0.4 ms. The spray angle of the solid cone spray increased with back pressure.

Web-IMS integration offers an opportunity to provide novel services that combine rich web contents and IMS real-time communication functions. A rich Internet application (RIA) is a promising way to provide Web-IMS cooperative services for web terminals without modification to the terminals. We propose an architecture that separates the IMS client function (SIP/RTP stack) from RIA as a shared SIP/RTP component. Web-IMS cooperative RIAs call the service-level APIs of the SIP/RTP component to use IMS communication functions so that web developers can implement Web-IMS cooperative RIAs without having expert IMS knowledge. We describe two system architectures; one dynamically deploys the component as an RIA and the other deploys the component at an external gateway. Prototype evaluation shows the feasibility of the architectures; the overhead of dynamic deployment is about 0.48 seconds, and the videophone latency caused by media translation at the external gateway is less than 132.8 milliseconds.

We propose the Service Control Technology for the Web-telecom coordination service, and we show our proposal effectiveness. In the NGN (Next-Generation Network), many new applications are expected using open network interfaces. In particular, we study the SDP (Service Delivery Platform) for coordinating existing Internet services and telecom services. In this paper, we propose the Service control technology, which handles common process required in the telecom trigger Web-telecom coordination service. Our method achieves improvement in usability of telecom user, reliability of the coordination service, and processing performance. We implement our method two types (Proxy type, Callable type) and measured processing performance. In comparison to related technologies, we show our method effectiveness.

In this paper, we propose efficient information search methods based on the user utility in super-distributed environments, where the released information can be renewed or deleted freely by administrators of independent information sites. In an efficient search, a user (or a searcher) can find the desired information with high satisfaction, i.e., user utility. Generally, the greater the search time and cost required in order to increase target discovery probability, the lower the user utility becomes. Here, we propose efficient methods for conducting searches for multiple targets. Especially, keeping in mind that utility decreases monotonically with time or cost, we give high priority to the search of the target information the utility of which decreases sharply. And finally, we show the effectiveness of the proposed methods by computer simulations.

Recently, the number of users of media services including video-sharing sites has been increasing as broadband networks spread. Since the number of media-streaming services is expected to increase in the broadcasting business, a lot of telecommunication companies think that the media services platform will become important in the future. To achieve such a platform, there are some requests in which systems are able to acquire data from NW easily and apply multi-step processing. Therefore, we have proposed a system that can freely process the streaming data on a network. In this paper, we report the arrangement of system devices, and the method to select data processing units, and the method that enables users to combine processing components easily. In addition, we report feasibility according to the evaluation result obtained in the prototype data processing unit. As a result, general users can add a variety of effects to media streams including existing services.

Using a newly developed driving method for AC-field-stabilized matrix ferroelectric LCDs, high contrast and flickerless displays are obtained in 1000 line multiplexing for rubbed and oblique-evaporated panels, each of them possessing 640 × 400 pixels of size 12 inch, 4 μm thick. In this paper, the novel driving method, the display performance, and dependancy of the AC stabilizing effect on cell thickness, are described.

We herein describe a surgical technique in a mitral valve replacement for a hemodialysis patient presenting with mitral valve stenosis and severe mitral annular calcification. Mitral annular calcification extending to the left ventricular myocardium was resected using a cavitron ultrasonic surgical aspirator (CUSA) to make a flat plane from the left atrium to the left ventricle. An autologous pericardium was secured to the posterior left ventricular wall and to the left atrial wall covering the mitral annulus for annular reconstruction. In the posterior mitral annulus, the prosthetic valve was fixed onto this pericardial patch. After the operation, the patient recovered well without any embolic complications. The prosthetic valve functions normally without any perivalvular leakage. Decalcification using the CUSA and the annular reconstruction with a pericardial patch is therefore indicated in valve replacement for patients with severe mitral annular calcification.